Early-session Microprocesses That Predict Retention In Substance Use Disorder Treatment: An Integrative Analysis Of Therapeutic Alliance Formation

3-EARLY-SESSION MICROPROCESSES THAT PREDICT RETENTION IN SUBSTANCE USE DISORDER TREATMENT .

Download • 241KB

Author: Jacob Rosedale, PhD, LPC

(affiliation National University, Bellevue University)

Abstract

Autonomy support has emerged as a critical yet under-specified component of effective addiction treatment. Although motivational and alliance-based frameworks emphasize the importance of client agency, the field has offered limited guidance regarding how autonomy is communicated in real-time clinical interactions, particularly during early treatment sessions. This article examines autonomy-supportive communication as a relational process enacted through therapist stance, language, and pacing during the initial phase of addiction treatment. Drawing on qualitative findings and a clinically grounded exemplar dialogue, the article illustrates how therapists support autonomy by managing ambivalence without confrontation, prioritizing relational safety over premature intervention, and using invitational language that preserves client agency. Rather than conceptualizing autonomy as a client trait or readiness variable, this work positions autonomy as an experience co-constructed within the therapeutic relationship. Clinical implications are discussed for therapist training and supervision, highlighting the need to explicitly teach alliance-centered micro-skills that are often assumed rather than modeled. By operationalizing autonomy-supportive communication in vivo, this article contributes to a more precise understanding of how early therapeutic interactions shape engagement, alliance formation, and sustained participation in addiction treatment.

INTRODUCTION

Substance use disorder (SUD) treatment continues to face persistent challenges related to early disengagement and premature dropout. Despite decades of advances in evidence-based therapies, many clients fail to remain in treatment long enough to benefit from it (Norcross & Lambert, 2019). A growing body of psychotherapy process research suggests that a critical determinant of whether clients remain engaged is not merely the modality employed, but rather the quality of the interactional processes that occur in the earliest minutes and sessions of treatment (Flückiger et al., 2018; Wampold & Imel, 2015). Yet, despite broad recognition that early alliance predicts treatment outcomes, far less attention has been directed toward the specific therapist microprocesses that shape these initial interactions and set the trajectory for engagement.

Therapeutic alliance has long been understood as a multidimensional construct encompassing agreement on goals, agreement on tasks, and the emotional bond between therapist and client (Bordin, 1979). However, emerging scholarship suggests that what therapists do moment by moment may be more predictive of early engagement than broad relational qualities alone (Horvath et al., 2011). Microprocess research highlights the importance of subtle, often rapid interpersonal behaviors such as empathic pacing, linguistic attunement, validation of ambivalence, responsiveness to emotional cues, and the degree to which therapists support clients’ psychological needs at the outset of care (Flückiger et al., 2018; Norcross & Lambert, 2019). In SUD treatment, where clients often begin therapy ambivalent, externally pressured, or discouraged by previous unsuccessful attempts, these microprocesses can determine whether the therapeutic relationship becomes a safe and motivating space or a brief, unsuccessful encounter (Wampold & Imel, 2015).

Self-Determination Theory (SDT) offers a compelling framework for understanding why earlysession therapist behaviors exert such powerful influence on engagement. Clients entering SUD treatment frequently experience diminished autonomy, weakened self-efficacy, and ruptured relational trust (Deci & Ryan, 2017). The ways in which therapists respond during the earliest interactions can either support or undermine clients’ basic psychological needs for autonomy, competence, and relatedness, which in turn shape motivation, openness, and willingness to return for subsequent sessions (Deci & Ryan, 2000). Despite the relevance of SDT to treatment engagement, the field lacks integrative models detailing how therapist microprocesses support these needs during the initial sessions and how these processes influence retention.

The purpose of this article is to address this gap by articulating a clear, clinically grounded, and theoretically coherent model of early-session microprocesses that foster alliance formation and predict continued engagement in SUD treatment. Integrating microprocess theory, alliance research, and SDT, this paper identifies therapist behaviors most essential in the first hour of treatment—behaviors that invite collaboration, support agency, build early competence, and establish a relational foundation experienced by clients as trustworthy and stabilizing.

By illuminating these mechanisms, this article aims to provide clinicians, supervisors, and training programs with actionable guidance for improving early engagement in SUD care. The proposed model not only clarifies how therapists help clients remain in treatment, but also deepens the field’s understanding of the relational conditions under which recovery becomes possible.

BACKGROUND AND THEORETICAL FOUNDATIONS

Early engagement in psychotherapy is shaped by a set of rapid interpersonal processes that occur before clients consciously evaluate therapist expertise or treatment suitability (Horvath et al., 2011). Microprocess theory conceptualizes therapeutic relationships as forming through moment-to-moment exchanges, including empathic timing, tone modulation, responsiveness to emotional cues, and the therapist’s stance toward client autonomy (Flückiger et al., 2018). These early relational signals shape client expectations regarding safety, collaboration, and agency. In substance use disorder (SUD) treatment, where ambivalence, shame, and external pressure are common, such microprocesses carry heightened importance and often determine whether clients return following the initial session (Norcross & Lambert, 2019).

Traditional alliance frameworks emphasize agreement on goals, agreement on tasks, and the emotional bond (Bordin, 1979). While these domains remain foundational, they do not fully capture the interactional subtleties through which therapists communicate respect, attunement, and motivational support in early encounters. Alliance formation is not simply the achievement of mutual understanding; rather, it is the co-construction of a relational environment that either supports or frustrates clients’ psychological needs (Wampold & Imel, 2015). Research suggests that the early trajectory of alliance formation often unfolds within the first minutes of interaction, rendering early-session therapist behavior a critical yet underexamined mechanism of engagement (Flückiger et al., 2018).

Clients entering SUD treatment frequently present with depleted psychological resources. Many report feeling coerced into treatment by legal systems, employers, or family members, while others arrive demoralized by repeated relapse or prior negative treatment experiences (Ryan & Deci, 2017). In this context, therapist behaviors function not merely as rapport-building gestures, but as signals that shape clients’ sense of agency, capability, and relational safety. Even minor missteps—such as premature confrontation, controlling language, or insufficient acknowledgment of ambivalence—may be experienced as invalidating, contributing to early disengagement (Miller & Rollnick, 2013).

Self-Determination Theory (SDT) provides a useful lens for understanding these processes. SDT posits three basic psychological needs essential for motivation and well-being: autonomy, competence, and relatedness (Deci & Ryan, 2000, 2017). When these needs are supported, individuals develop more internalized, self-directed forms of motivation; when they are thwarted, motivation becomes externally driven and fragile. Clients in SUD treatment often arrive with all three needs compromised. Their autonomy is constrained by addiction and external mandates, competence is weakened by repeated unsuccessful change attempts, and relatedness may be strained by stigma or relational rupture.

Therapist microprocesses in early sessions play a direct role in addressing—or exacerbating— these vulnerabilities. Autonomy is supported through interactional stances that privilege choice, validate ambivalence, and avoid coercive language (Miller & Rollnick, 2013). Competence is supported when therapists reflect strengths and provide guidance without overwhelming clients. Relatedness is supported through genuine curiosity, empathic pacing, and emotional attunement (Deci & Ryan, 2017). Together, these microbehaviors create conditions that foster engagement and increase the likelihood of continued participation in treatment.

Section 3: Autonomy-Supportive Communication in Early Addiction Treatment

Purpose and Link to the Research Questions

The purpose of this section is to operationalize autonomy-supportive communication as it is enacted in early addiction treatment and to demonstrate how specific therapist behaviors contribute to the formation and maintenance of the therapeutic alliance. While prior sections outlined the theoretical foundations informing this study, the present section illustrates how those principles are translated into moment-to-moment clinical practice. Research on psychotherapy process consistently suggests that early-session therapist behaviors exert a disproportionate influence on engagement and retention, particularly in populations vulnerable to ambivalence and disengagement (Flückiger et al., 2018; Horvath et al., 2011).

This section directly addresses Research Question 1, which explored how addiction therapists describe establishing a therapeutic alliance in early sessions, and Research Question 2, which examined therapist behaviors perceived as essential to sustaining that alliance over time. Across participant narratives, early-session communication emerged as a critical site where alliance, motivation, and engagement either begin to coalesce or quietly erode. These findings are consistent with alliance research demonstrating that early relational quality predicts subsequent engagement and outcomes across treatment modalities (Norcross & Lambert, 2019; Wampold & Imel, 2015).

Rather than treating autonomy as an abstract construct or client attribute, this section conceptualizes autonomy as a relational experience, communicated implicitly through therapist stance, language, and pacing during the opening phase of treatment. This perspective aligns with Self-Determination Theory’s emphasis on autonomy as a context-dependent psychological need that is either supported or thwarted through interpersonal interaction (Deci & Ryan, 2000, 2017).

Autonomy as a Relational Experience in Early Sessions

Participants consistently described autonomy not as the absence of structure or direction, but as the client’s felt sense of being respected, understood, and free to engage at their own pace. Autonomy was conveyed less through explicit discussion and more through how therapists positioned themselves relationally, particularly during the first session. This finding reflects broader psychotherapy research indicating that alliance formation is shaped by implicit relational signals rather than overt declarations of intent (Horvath et al., 2011).

Several participants emphasized that clients frequently arrive ambivalent, externally motivated, or uncertain about their readiness for change. In these contexts, attempts to assess, educate, or motivate too quickly were described as counterproductive, often increasing defensiveness or disengagement. Instead, autonomy was supported when therapists prioritized psychological safety, emotional presence, and relational pacing over early information gathering or goal clarification. These observations are consistent with motivational and alliance research demonstrating that premature directive interventions can undermine engagement, particularly in addiction treatment contexts (Miller & Rollnick, 2013; Norcross & Lambert, 2019).

These findings align directly with RQ1, highlighting that alliance formation begins not with intervention delivery, but with how therapists respond to uncertainty, resistance, and mixed motivation in the earliest moments of contact. Early autonomy support appears to function as a relational signal that therapy will be collaborative rather than coercive, thereby increasing clients’ willingness to remain engaged (Deci & Ryan, 2017).

Therapist Stance as a Foundation for Alliance

A defining feature across participant accounts was the therapist’s stance during the opening minutes of treatment. Participants described deliberately slowing the process, resisting the urge to “do therapy,” and signaling to clients that they were not being evaluated, managed, or pressured toward predetermined goals. This stance reflects an intentional prioritization of alliance formation over procedural efficiency, consistent with research emphasizing the importance of therapist responsiveness in early sessions (Flückiger et al., 2018).

This stance was characterized by emotional availability rather than task orientation, curiosity rather than hypothesis testing, permission-based direction rather than implicit authority, and comfort with ambiguity rather than premature problem-solving. Importantly, participants did not describe this approach as passive or unstructured. Rather, it represented a disciplined containment of therapist expertise in service of relational safety and engagement. Similar patterns have been identified in alliance research linking therapist restraint and attunement to stronger early alliances (Wampold & Imel, 2015).

This finding speaks directly to RQ2, as participants viewed this restrained, autonomy-supportive stance as essential not only for alliance formation but for sustaining engagement over time. Therapists described that when clients experienced early interactions as non-coercive and respectful, they were more likely to return, disclose honestly, and tolerate the discomfort inherent in change-oriented work (Norcross & Lambert, 2019).

Language as a Vehicle for Autonomy Support

Participants repeatedly noted that language choices—often subtle and habitual—either supported or undermined client autonomy. Autonomy-supportive language was described as invitational, tentative, and collaborative, allowing clients to remain undecided without pressure to resolve ambivalence prematurely. Such language communicates respect for client agency and aligns with evidence demonstrating that perceived autonomy support enhances motivation and engagement (Deci & Ryan, 2000, 2017; Deci et al., 2017).

Conversely, directive or prescriptive language, even when clinically accurate, was experienced by clients as controlling or dismissive when introduced too early. Participants emphasized that early reflections prioritized meaning and emotional experience over behavior change or symptom reduction. This emphasis reflects findings from motivational and alliance-based research indicating that early confrontational or corrective language may increase resistance and undermine alliance strength (Horvath et al., 2011; Miller & Rollnick, 2013).

This pattern further reinforces RQ1, demonstrating that alliance formation is facilitated through language that communicates respect for the client’s internal process rather than urgency for change. Language thus functions not merely as a vehicle for intervention delivery, but as a primary mechanism through which autonomy is either supported or constrained.

Managing Ambivalence Without Undermining Agency

Ambivalence emerged consistently across participant narratives as a normative and expected feature of early addiction treatment rather than as a sign of resistance or poor motivation. Therapists described viewing clients’ simultaneous desires to change and to maintain familiar coping strategies as understandable responses to threat, loss of control, and prior treatment failures. This framing aligns with process research indicating that ambivalence is a developmental marker of engagement, particularly in contexts where change carries significant psychological and relational risk (Deci & Ryan, 1985; Horvath et al., 2011; Miller & Rollnick, 2013).

Participants emphasized that autonomy-supportive responses to ambivalence required restraint rather than persuasion. Therapists described intentionally allowing contradictory feelings to coexist without pressuring clients toward resolution or commitment. Such responses included reflecting uncertainty without amplifying it, normalizing hesitation without minimizing consequences, and maintaining a collaborative tone despite clinical concern. These behaviors are consistent with alliance research demonstrating that non-coercive engagement reduces psychological reactance and strengthens early alliance quality (Horvath et al., 2011; Wampold & Imel, 2015).

Importantly, participants distinguished autonomy support from passivity. While therapists avoided directive or corrective responses in early sessions, they remained actively engaged, emotionally present, and attuned to shifts in client affect. This balance allowed clients to experience agency without abandonment and containment without control. From an SDT perspective, such interactions support autonomy while simultaneously fostering relatedness and competence, thereby promoting more internalized motivation over (Deci & Ryan, 2000, 2017).

These findings directly address RQ2, highlighting that how therapists manage ambivalence in early sessions has lasting implications for alliance maintenance. Participants described that when clients felt their ambivalence was tolerated rather than challenged, they were more willing to remain in treatment, disclose honestly, and explore change at their own pace. Conversely, attempts to resolve ambivalence prematurely were often associated with withdrawal, compliance without engagement, or early dropout. Managing ambivalence without undermining agency therefore emerged as a central relational mechanism through which early alliance is stabilized and sustained.

Exemplar Dialogue: Autonomy-Supportive Communication in the First Session

The following dialogue represents an amalgamated participant profile, constructed from recurring themes, language patterns, and relational strategies described across multiple therapist interviews. The exemplar reflects an experienced addiction therapist whose clinical approach emphasizes alliance, autonomy support, and relational pacing in the opening phase of treatment.

The dialogue captures approximately the first ten minutes of an initial session and illustrates how autonomy-supportive communication is enacted in vivo. It is presented without narration to preserve its experiential integrity.

Therapist: Before we jump into anything, I want you to know there’s no agenda you have to meet today. We can start wherever it makes sense for you.

Client: I appreciate that. I’m honestly not sure why I’m here exactly.

Therapist: That’s okay. Not knowing is a pretty common place to start. What do you notice yourself feeling as you sit here right now?

Client: I guess it’s a little guarded. I’ve done this before. It usually turns into someone telling me what I should do.

Therapist: You’ve had experiences where it felt more like being directed than understood.

Client: Yeah. And that just makes me shut down.

Therapist: I’m glad you’re saying that. My hope is that this feels different. We’ll move at your pace, and we’ll figure things out together.

Client: I don’t even know what I want to change yet.

Therapist: You don’t have to decide that now. We can spend time understanding what feels stuck before talking about what might change.

Client: That takes some pressure off.

Therapist: Good. Pressure usually gets in the way of honesty. What feels most important for me to understand about your situation?

Client: I guess… how tired I am of going back and forth in my head. Therapist: That back-and-forth sounds exhausting. We can slow it down here and make some sense of it together.

Clinical Implications for Alliance-Focused Addiction Treatment

The findings presented in this section suggest that autonomy-supportive communication is not an adjunct to effective addiction treatment, but a core mechanism of alliance formation and maintenance. Across participant accounts, early-session therapist behaviors that prioritized autonomy, relational pacing, and emotional attunement were consistently linked to greater honesty, reduced defensiveness, and sustained engagement over time. These observations align with broader psychotherapy research positioning the alliance as an active ingredient of change rather than a contextual variable (Flückiger et al., 2018; Norcross & Lambert, 2019).

For clinical training, these findings underscore the need to explicitly teach autonomy-supportive communication as a set of observable, practice-based skills. Many therapists are encouraged to value collaboration and respect client agency, yet receive limited guidance on how to enact these principles under conditions of ambivalence, external pressure, or institutional constraint. Without concrete exemplars, trainees may default to directive or corrective approaches that inadvertently undermine alliance, particularly in mandated or high-risk treatment contexts (Miller & Rollnick, 2013).

Supervisory practices also warrant reconsideration. Supervision that prioritizes intervention selection or symptom reduction without attending to relational process may reinforce therapist urgency and diminish sensitivity to alliance dynamics. In contrast, supervision that tracks therapist stance, language use, and responses to ambivalence can strengthen clinicians’ capacity to support autonomy while maintaining therapeutic containment. Such approaches are consistent with evidence linking therapist responsiveness and alliance quality to improved engagement and outcomes (Horvath et al., 2011; Wampold & Imel, 2015).

At a broader level, emphasizing autonomy-supportive communication reframes early addiction treatment as a relational foundation rather than an intervention-delivery phase. This shift has meaningful implications for reducing early dropout, enhancing engagement, and supporting durable recovery trajectories. By grounding early-session practice in the psychological needs of clients with substance use disorders, therapists can create conditions in which motivation emerges organically and the therapeutic alliance becomes a stable platform for change.

Section 4: Discussion

The present article sought to elucidate how autonomy-supportive communication is enacted in early addiction treatment and how such communication contributes to the formation and maintenance of the therapeutic alliance. Building on psychotherapy process research, alliance theory, and Self-Determination Theory (SDT), the findings highlight autonomy not as an abstract principle or client characteristic, but as a lived relational experience co-constructed through therapist stance, language, and pacing during the opening phase of treatment (Deci & Ryan, 2000, 2017).

Across participant accounts and the exemplar dialogue, alliance formation emerged less as a function of specific techniques and more as a consequence of how therapists positioned themselves in relation to clients. Early interactions characterized by emotional availability, restraint, and permission-based engagement appeared to foster psychological safety, allowing clients to express ambivalence without fear of judgment or coercion. This finding is consistent with alliance research demonstrating that therapist responsiveness and attunement are robust predictors of engagement and outcome across treatment modalities (Flückiger et al., 2018; Horvath et al., 2011).

Importantly, the findings suggest that autonomy-supportive communication serves a dual function in addiction treatment. In early sessions, it facilitates alliance formation by reducing defensiveness and psychological reactance. Over time, it supports alliance maintenance by reinforcing clients’ sense of agency and ownership over the therapeutic process. This distinction extends existing alliance research by specifying how autonomy is communicated moment by moment, particularly within the complex relational landscape of substance use disorder (SUD) treatment, where clients frequently present ambivalent or externally motivated (Norcross & Lambert, 2019; Wampold & Imel, 2015).

The results further challenge treatment approaches that prioritize early assessment, goal setting, or behavior change at the expense of relational attunement. While such strategies may be administratively efficient, they risk undermining the very alliance upon which sustained engagement depends—especially for clients entering treatment with histories of coercion, stigma, or prior treatment failure. Viewed through an SDT lens, premature directive interventions may inadvertently thwart autonomy and competence, thereby weakening motivation and increasing dropout risk (Deci & Ryan, 2000, 2017).

Section 5: Clinical and Theoretical Implications

Clinical Implications

From a clinical standpoint, these findings underscore the necessity of reframing early addiction treatment as a relational phase rather than an intervention-delivery phase. Therapists who prioritize autonomy-supportive communication during initial sessions may be better positioned to establish trust, reduce early dropout, and facilitate deeper engagement over time. This approach does not require abandoning structure or clinical expertise; rather, it involves the intentional sequencing of interventions so that relational safety precedes directive change efforts (Miller & Rollnick, 2013).

The exemplar dialogue illustrates that autonomy support is enacted not through the absence of guidance, but through the strategic containment of therapist urgency. This stance demands clinical maturity, including tolerance for ambiguity, confidence in the therapeutic process, and comfort with not resolving ambivalence prematurely. Research suggests that such restraint is associated with stronger alliances and greater client openness, particularly in populations vulnerable to reactance (Horvath et al., 2011; Wampold & Imel, 2015).

For training and supervision, these findings indicate that autonomy-supportive communication must be explicitly modeled rather than implicitly assumed. Many trainees endorse collaborative values yet struggle to translate them into practice under pressure. Without concrete exemplars of alliance-centered microprocesses, therapists may default to directive or corrective responses that undermine engagement—especially in mandated or high-risk treatment contexts (Norcross & Lambert, 2019).

Theoretical Implications

Theoretically, this work contributes to a growing literature positioning the therapeutic alliance as a dynamic, co-constructed process rather than a static variable. By grounding autonomy within observable therapist behaviors and interactional patterns, the findings help bridge the gap between motivational theory and clinical process research (Deci & Ryan, 2000, 2017). Moreover, the results support a relational conceptualization of motivation, suggesting that autonomy support functions not as a client trait or readiness prerequisite, but as an emergent property of the therapeutic relationship. This perspective aligns with contemporary models of psychotherapy that emphasize context, interaction, and responsiveness as central mechanisms of change (Flückiger et al., 2018; Wampold & Imel, 2015).

Section 6: Limitations and Future Directions

Several limitations should be acknowledged. First, the exemplar dialogue presented in this article represents an amalgamation of therapist perspectives rather than a verbatim clinical transcript. While this approach enhances conceptual clarity and preserves participant confidentiality, it necessarily abstracts from individual variation in therapist style, client presentation, and contextual factors (Smith et al., 2022).

Second, the findings reflect therapist perceptions of effective alliance-building behaviors. Although these perspectives are valuable for understanding clinical decision-making, future research would benefit from incorporating client-reported experiences of autonomy support and alliance quality to more fully capture the relational process from both sides of the dyad (Horvath et al., 2011).

Future studies might also examine how autonomy-supportive communication operates across different treatment settings, levels of care, and cultural contexts, as well as how external pressures—such as court mandates or family involvement—interact with early-session microprocesses. Quantitative research exploring associations among early autonomy support, alliance strength, retention, and outcomes would further strengthen the empirical foundation for the model proposed here (Flückiger et al., 2018; Norcross & Lambert, 2019).

Conclusion

Autonomy-supportive communication represents a clinically potent yet often under-specified component of effective addiction treatment. By illustrating how autonomy is communicated through therapist stance and language in early sessions, this article highlights the central role of relationship in fostering engagement, motivation, and sustained change. Ultimately, the findings suggest that in addiction treatment, how therapists communicate may matter as much as what they communicate. When clients experience therapy as collaborative, respectful, and autonomy-supportive, the therapeutic alliance becomes not merely a foundation for change, but the change process itself.

References

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy (Chicago, Ill.), 16(3), 252–260. 10.1037/h0085885

Deci, Olafsen, & Ryan. (2017). Self-Determination Theory in Work Organizations: The State of a Science. Annual Review of Organizational Psychology and Organizational Behavior, 4(1), 19–43. 10.1146/annurev-orgpsych-032516-113108

Deci, & Ryan. (1985). Intrinsic motivation and self-determination in human behavior (1st ed.). Springer Science+Business Media. 10.1007/978-1-4899-2271-7

Deci, & Ryan. (2000). Self-Determination Theory and the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. American Psychologist, 55(1), 68–78. 10.1037/0003- 066X.55.1.68

Deci, & Ryan. (2017). Self-Determination Theory: Basic Psychological Needs in Motivation, Development, and Wellness (1st ed.). Guilford Press. 10.1521/978.14625/28806

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Psychotherapy (Chicago, Ill.), 55(4), 316–340. 10.1037/pst0000172

Horvath, Del Re, Flückiger, & Symonds. (2011). Alliance in Individual Psychotherapy. Psychotherapy (Chicago, Ill.), 48(1), 9–16. 10.1037/a0022186

Miller, W., & Rollnick, S. (2013). Motivational interviewing: Helping People Change (3. ed. ed.). Guilford Press.

Norcross, & Lambert, M. J. (2019). Psychotherapy Relationships That Work (3rd ed.). Oxford University Press, Incorporated.

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate (Second edition ed.). Routledge. 10.4324/9780203582015